Harm Reduction Groups – Meeting Drug Users Where They Are 

Anna Berg, LCSW, and Jeannie Little, LCSW 

“The only requirement for membership in Alcoholics Anonymous is a desire to stop drinking.” This  oft-repeated phrase is a testament to the low-threshold nature of AA and its sister 12-step programs.  Harm reduction therapy and harm reduction therapy groups are even lower threshold – we reach out to  the majority of substance abusers who do not have a desire to stop drinking (or using), do not avail  themselves of existing treatment or self-help resources, and who continue to use alcohol and other drugs  despite incurring actual or potential harm.  

Harm reduction is a “come as you are” approach that welcomes drug users into a helping  relationship and allows them to set their own goals. In harm reduction work, a myriad of outcomes, not  just abstinence, are considered to be helpful (harm reducing). Moderation is often an outcome of  problem drinking (Rotgers, Kern, Hoetzel, 2002; Saladin and Santa Ana, 2004). In our experience, we  witness many varieties of success in overcoming problems with drugs. For example, one person has quit  crack, learned to drink moderately, and continues to use medical marijuana, while another has stopped  shooting heroin, goes on methadone maintenance, but still struggles with alcohol abuse. A third, in  danger of losing her job, has quit all psychoactive substances, while a fourth who is HIV positive has  committed to using condoms during while still using crystal meth (speed), and a fifth now hands his car  keys to the bartender as soon as he enters the bar.  

Harm reduction groups have members with widely divergent goals about future use, from harm reducing changes to moderation to abstinence, and they provide an opportunity for group members to  witness the continuum of drug use consequences without having to experience them all themselves!  Members also get to witness the varieties of progress and success. Just as drug use occurs on a  continuum from benign to useful to problematic to lethal, a continuum that for most people takes a long  time to develop, so does the undoing of problematic patterns of drug use occur on a continuum that is  much more gradual than the often hoped-for dramatic conversion to abstinence after a person “hits  bottom.” Abstinence is one of many valuable harm reduction solutions to the problems people  encounter with drugs, but it is not the only one.  

Harm reduction groups are inclusive and work to empower clients to make decisions about their  lives that result in positive changes and decreased harm (Little, 2002). Harm reduction groups do not  screen members for drug use or demand drug testing. It would be pointless to invite active users into a  group, only to then screen their urine for drugs! Nor do harm reduction groups mandate attendance or  that group members make changes in their drug use.  

Instead, we take responsibility for creating a culture that is sufficiently welcoming that members  will eventually feel comfortable telling us what they are using, how often, and how much. This is a  much more productive way to enter into a treatment relationship than the practice of policing people’s  urine or enforcing hard-to-enforce rules. As therapists, we work to establish a strong therapeutic  alliance to help our clients facilitate change. Using our relationship-building tools, we find that people  move quickly to telling us what they are using, how and why. They become curious about what we  might have to offer as we explore whether they are ready for new information and assess their  motivation for change.

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In our community programs, diverse drug use histories, practices, and consequences are  complicated by mental illness, homelessness, poverty, and PTSD (see previous paper in this chapter).  To accommodate the full range of people’s issues and level of functioning, all of our groups are drop-in.  People’s mental status and lives, as well as the unpredictability of attendance on any given day, mean  that community-based harm reduction groups can be volatile as well as unpredictable. Sometimes it is  difficult to see, amidst the chaos, the ways in which people are developing motivation and changing. 

Group Vignette 

The Harm Reduction Support Group begins in its usual way: doors to the group room open at 1:30pm,  coffee, chairs and facilitator are ready and waiting. I welcome the group with an introduction that many  have heard before, while group members get coffee and mill about, getting settled. During the session,  13 people joined us. 

“Hello! Welcome to the Harm Reduction Group. I’m Anna and we meet every Monday, Wednesday  and Friday from 1:30-2:30pm in this room. This is a Harm Reduction group, so everyone is welcome  just as they are, whenever they get here—even if they join us five minute before we end! There are no  

real rules for this group, other than you can come and go as you need to—whether you need to pee, take  a drug break, just aren’t feeling it or you have some other place to be, you make the call. Also, we call  everyone here as they introduce themselves. Lastly, we do not allow threats of any kind in this group— this is harm reduction! Help yourself to coffee or juice and let’s start with check-ins. Anyone want to  start us off? “ 

Casey, a 40-year old IV drug user who has advanced HIV and bi-polar disorder, jumps right in, directing  his comments to the facilitator while wriggling in his chair, his foot tapping on the floor. “I really need  to check in about my landlord. I think he knows I use and wants to kick me out. When I signed my  lease it said “no drug use of any kind” or they can evict you. Do you think he knows? I put towels  under all my doors and windows…” 

Kurt, a 55 year-old veteran with a traumatic head injury, rolls his eyes towards Casey. “Yeah, man. Of  course they know. This is the Tenderloin—the F-in’ drug den of the world! He probably just wants you  to share.” At this, he kicks back his chair and goes to get coffee as Tasha enters the room. Casey  continues to wiggle in his chair, almost as if he were vibrating. 

“Hihihihi everybody!” announces Tasha, a mother of three in her forties, though she appears much  older. “I just got to get in here, make some room for me, here I come. I can’t get in…oh, okay, thanks.”  Tasha typically enters group this way—announcing herself and asking others to make room for her.  Tasha has multiple sclerosis, which many group members know, as well as PTSD; as a woman, she is  extended courtesies that many male members would not extend to each other. Franco moves his chair so  that Tasha can sit close to the door. I welcome Tasha and, to help the group stay focused, let her know  that we were checking in with Casey.  

Casey continues to verbalize his worry about his landlord, this time directing his questions to Kurt. They get into an argument when Kurt uses the phrase “Damn straight”. Casey is gay, Kurt knows this, and he  laughs awkwardly at the misunderstanding, while Casey revvs up. 

Franco jumps in to help. Franco is a slight man with schizophrenia who speaks English as a second  language; group members often have a hard time understanding him. Today, he seems to be more 

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organized. “It’s okay, man. He just means maybe your landlord thinks you use medical marijuana or  something. Maybe he don’t know about the speed.” 

Franco’s intervention calmed Casey down long enough for Kyle to jump in. Kyle, in his fifties, is  diagnosed with schizophrenia and a heavy speed user. He wants to talk about medical marijuana. I  interrupt him so we don’t get de-railed, and ask his permission to pose a question to Casey before  answering his questions about medical marijuana. Kyle agreed, although he had challenges sticking  with this agreement and needed gentle reminding. 

I tried to draw out the meaning behind Casey’s sudden anxiety about his landlord. “Casey, you seem  really upset about your landlord, and worried that he might evict you. Would it be helpful to say more  about what is bothering you so much today?” 

After a long pause, Casey disclosed that his drug connection had trashed his apartment the night before,  causing damage to the building. This resulted in complaints from neighbors to the landlord. Casey was  interrupted by Tasha, who wanted to know what drug Casey used, and by Kurt, who began to talk about  the futility of harm reduction. I reminded Tasha and Kurt that in the Harm Reduction Support Group,  

we ask people for their permission before we give them feedback, and encouraged them to get Casey’s  okay before commenting on his situation. Casey continued, saying “The feedback’s okay. It’s okay that  Kurt said harm reduction is dumb. I know I should quit; my doctor says I need to quit—I only have four  T-cells.”  

DJ, a large, soft-spoken man with an extensive history of trauma, commented that he tried abstinence  and that it didn’t work for him. He suggested to Casey that just because his doctor wanted him to quit,  that probably wouldn’t be enough to motivate him. 

Following DJ’s lead, I reminded the group that in harm reduction, what works for one person doesn’t  always work for everyone. Each person has their own reasons for using and reasons for wanting to  change; we call this the decisional balance. I asked the group if they could help Casey think about the  pros and cons of speed, with lively results. Kurt joined the side of Casey that wanted to change his use,  pointing out that he was jeopardizing his housing, health and maybe the victim of violence since his  connection seemed to be unpredictable. Kellie, a round-faced woman in her early fifties who had  previously seemed checked out from the conversation, offered to help Casey clean his apartment,  suggesting that he “make use of” his high by cleaning up. Tasha sided with the part of Casey who worried about his health, sharing her own stories of struggling with crack and MS, while Kyle joined  with the side of Casey who liked getting high, talking about medical marijuana and the benefits of  getting high “to get away.”  

The discussion proceeded while an unfamiliar young man in the corner nodded out on opiates and  Franco got more coffee. Vaughn entered the room, thumping a Bible. “Here I am!” he shouted. “I  brought the word with me too!” Kyle became impatient to check in and hear from others. While others grumbled that we were running out of juice. 

“You’re right! We need to check in with other folks. There are many pressing needs in this group. Can  we find out first if we have helped Casey resolve his dilemma?” Casey reported that he felt less  pressure to make a decision about his relationship with speed and a little less anxious that he might be  evicted.

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The group proceeded, as it usually does, with attention to various issues such as the virtues of marijuana; a female member’s current domestic violence situation; a biblical lesson from Vaughn, which the group  barely tolerated; always with people coming and going, getting coffee and juice, and both supporting  and irritating each other, all at the same time. 

Deconstructing What Happens in a Harm Reduction Group 

Drop-in groups are all-inclusive 

Drop-in groups are the lowest threshold form of group treatment and, as such, welcome some of the  most chaotic and complicated clients in community mental health. Many clients are not able to keep  appointments or follow behavioral expectations of closed session groups, nor are they able to tolerate  prolonged contact with others. (Think of Kyle or Vaughn in the above group example.) In a drop-in  group, people attend as they need or wish. They are thereby able to “dose” themselves with treatment,  much as they dose themselves with drugs; such a model affirms that the client is the expert and knows  her needs. This, in turn, lowers resistance and allows us to avoid potential power struggles by placing  authority in the hands of the client. Furthermore, drop-in groups replicate the organic, nonlinear change  process identified by the stage model of change (Prochaska, DiClemente, and Norcross, 1992). And it  supports client self-efficacy, a key ingredient for motivation to change (Miller and Rollnick, 2002). 

Harm reduction groups accept everything 

The primary challenge to promoting acceptance of the adaptiveness of drug use is the cultural  dominance of the disease model of addiction. The disease model insists that abstinence is the only  rational response to out-of-control drug use. This attachment to the culture of “clean and sober” has  created challenges to treatment, as people who are most at-risk due to problematic drug use are  frequently screened out of care. This encourages clients to lie about their drug use if they don’t want to  be rejected. As a result, people are not accustomed to talking openly with a therapist about the details of  their drug use and many have a challenging time sharing about their use in groups. 

The leader of a harm reduction group must create a counter-culture of acceptance of drug use by  constantly reinforcing that people use drugs for reasons and by asking group members to talk about  those reasons. To create an environment of acceptance, or radical acceptance as a Buddhist might say,  the leader models empathy and respect for each person’s chosen means of coping (think about the  differences in Kurt, Casey’s and the nodding out young man’s coping methods in the above group  example). The leader does much reframing in order to combat the conventional view that continued  drug use represents failure. The idea is to lower clients’ resistance to change be encouraging them to  accept their present circumstances, and each other.  

Group members are the experts 

In harm reduction groups, members tell their own story. No one’s relationship with drugs is the same as  anyone else’s, and no one’s story (or drug!) is better than any other’s. By not defining problems from  any particular perspective, such as the disease model of addiction, harm reduction groups create  conditions that encourage each individual to explore their own experiences with drugs. The practice of  not demanding any particular behavior, including attendance, affirms each person’s autonomy and  builds self-efficacy. As members of the group often say, “each of us knows what we need, including  whether to be here or not. No one else can tell us what we need.” 

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Members talk about whatever they want 

To reinforce that group members are the experts, the leader of a harm reduction group must not set an  agenda. In other words, it is not for the leader to decide what is important. Group members can decide  in advance what topics are of interest to them so that the group leader, or a designated member, can  come prepared with information on those topics. Or the group can be structured in such a way that topics  of interest are arrived at spontaneously during the course of a check-in. Typically in harm reduction  groups approximately 50% of group time is devoted to talking about drug use and change. Members  also talk about emotional issues, struggles to survive, relationships, family, and treatment (e.g., HIV or  psychiatric) adherence.  

And there are almost no rules… 

A harm reduction drop-in group must operate with little-to-no rules in order to accommodate the most  chaotic, complex and at-risk drug users. Most people who experience problematic drug use have severe  emotional challenges (Denning and Little, 2011), and people who come to community mental health  centers are even more complicated. The only rules are those imposed on the leader: Successful drop-in  groups always start and stop on time, are rarely canceled, are held it the same location whenever  possible, and begin in the same way each time. This structure helps contain anxiety by helping clients  know what to expect. It also helps clients learn that they can count on the help provided by the drop-in  group, and encourages them to add group attendance to their list of coping skills. By offering a  structured group with few rules, there is less opportunity for punishment or feelings of failure if one  does not or cannot abide by the rules, thus increasing self-efficacy and helping to build momentum for  change. By eliminating rules, the group builds its own norms and has to actively work to include  challenging members. (Think of Vaughn, Kyle or Tasha in the group example.) This is crucial to not  just engaging vulnerable people, but also in providing client-centered, efficacious treatment.  

References 

Denning, P. and Little, J. (2011) Practicing Harm Reduction Psychotherapy: An Alternative Approach  to Addictions, 2nd Edition. New York: Guilford Press. 

Little, J. (2002). The sobriety support group: A harm reduction group for dually diagnosed adults. In A. Tatarsky (Ed.), Harm reduction psychotherapy: A new treatment for drug and alcohol problems. New Jersey: Jason Aronson. 

Prochaska, J.O., DiClemente, C.C., and Norcross, J.C. (1992). In search of how people change:  Applications to addictive behaviors. American Psychologist, 47: 1102-1114. 

Rotgers, F., Kern, M., and Hoeltzel, R. Responsible Drinking: A Moderation Management Approach for  Problem Drinkers. New Harbinger. 2002. 

Saladin, M. E. Santa Ana, E.J., (2004). Controlled Drinking: More Than Just a Controversy. Current  Opinions in Psychiatry 17(3):175-187, 2004. Lippincott Williams & Wilkins.

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